MENDOZA, Jemi Isabella M.

BSN-3B

NCM103 Medical ward 081011

University of the East RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER INC. #64 Aurora Boulevard, Brgy. Doa Imelda Quezon City 113 COLLEGE OF NURSING Nursing Care Process
I. CLIENTS PROFILE Name: Ms. A Age: 20 years old Address: San Juan City Birth date: January 13, 1991 Height: 4 feet and 11 inches Weight: 50 kg. Occupation: Home Service Massage Therapist Educational Attainment: High School Graduate Admission Data: Date of Admission: August 6, 2011 12:21 p.m. Admitting Diagnosis: Possible dengue fever Attending physician: Maribeth Delos Santos, M.D. II. CHIEF COMPLAINT Di mawala wala yung lagnat ko. As in bumabalik pa rin paminsan minsan. III. HISTORY OF PRESENT ILLNESS 5 days prior to admission, the patient had fever which was accompanied by pricking headache. She medicated herself with bioflu every 4 hours for that day that made a temporary relief. 2 days prior to admission, the patient had her CBC test taken at UERM that showed that her PC=150. They gave her paracetamol and allowed her to be discharged. 1 day prior to admission, the patient went to UERM ER due to intermittent fever. PC=108. From then on, she has been hospitalized. IV. PAST MEDICAL HISTORY The patient as a child was completely immunized since she got the following vaccines: DPT, BCG, Hepa B Measles and OPV. Last 2001, she was hospitalized due to irregular menstruation and was advised to take contraceptive pills for 3 months. She has never been allergic into anything as well as did she acquire any serious surgery. Gender: Female Civil Status: Single Nationality: Filipino Religion: Roman Catholic

V. FAMILY HEALTH HISTORY LEGEND: HTN -Hypertension UTI -Urinary Tract Infection -Deceased -Patient
VI. PSYCHOSOCIAL HISTORY
HTN/U TI

Ms. A is a massage therapist. She works from different homes that would gladly open their door for therapy but lately she acquired a possible dengue fever. Since then, she was not able to go out and work freely. She lives with her father along with her other relatives way back in Bicol. As of now, Ms. As father takes care of her. Her support system has a good foundation due to the accompaniment of her family, friends, and special someone. VII. DEVELOPMENTAL HISTORY

According to Erik Ericksons 6th stage of developmental theory, young-aged adult which is Intimacy vs. Isolation, Intimacy is the concern in establishing relationships that are intimate, choosing a lifestyle and adjusting to it, deciding on an occupation and managing home and family. While Isolation is the other way around, in which one prefers to be alone and work with his own. Most people in this category focus on career. The patient chose to work as a massage therapist to help in earning a living for her family. She also helped in the payment of tuition fees of her siblings. Ms. A values her family more than anything. She chose a lifestyle and adjusted to it to make a better life. The patient is happy serving her family. Thus, patient successfully passed the stage of Intimacy of Erik Ericksons 6th stage of development theory. VIII. GORDONS FUNCTIONAL HEALTH PATTERN a. Health Perception-Health Management Pattern Subjective data: Okay naman yung kalagayan ko bago dumating tong sakit ko. Gusto ko na gumaling para syempre makapagtrabaho uli ako. Madalas naman ako kumakain ng fruits pati gulay bago pa ako maadmit at iniinom ko naman on time yung gamut kung kailangan at meron man. Objective data: Patient is awake, irritable, well-groomed; slowed reaction, does not maintain eye contact, short attention span upon interview; has good posture and steady gait; oriented in time, person and place; with good memory of recent and remote events; Head no palpated mass or lesions noted; no enlarged lymph nodes; Eyelid margins moist and pink; lashes short, evenly distributed; upper margins of lid cover approximately 3 mm; palpebral conjunctiva pinkish in color with no discharge noted; illuminated pupils constrict in 3 mm; EOMs intact in both eyes; Nostrils can identify scent correctly; can perform different facial expressions; (+) in Webers Test, Rinne Test = 2 AC : 1 BC; forehead, cheeks and chin sensitive to light touch, dull, sharp sensation; vital signs monitored are as follows: Temperature: 36.7C, Pulse rate: 60 bpm, Respiratory rate: 19 bpm, Blood pressure: 110/80 mmHg; Height: 4 11, Weight: 50 kg, BMI: 22.2 kg/m2 Analysis: Readiness for enhanced therapeutic regimen

B. Nutrition-Metabolic Pattern Subjective data: Mas naging normal na yung pag-kain ko kasi apat na beses na ako kumakain sa isang araw. Mahilig ako kumain ng prutas pati gulay. Di naman ako mahilig sa mga matatabang pagkain. Objective data: Patients skin is reddish with noted petechiae, thick, warm, and dry to touch; no lesions noted; Hair is black and well-distributed; Nails are round, firm and pinkish in color; oral mucosa is moist, no lesions noted; gums pink in color; Height: 411,Weight:50kg, BMI: 22.2kg/m2 (within the normal range), patient is in DAT with the exception of dark colored drinks/food. Analysis: Readiness for enhanced nutrition C. Elimination Pattern Subjective data: Normal naman yung kulay ng dumi ko. Walang dugo o kung anuman. Ganun din pagihi ko. Objective data: Patient has a normal body built; abdomen symmetrical, no visible pulsations or peristaltic motions noted on the abdomen; absence of arterial bruits and friction rub upon abdominal auscultation Analysis: Readiness for enhanced urinary elimination D. Activity-Exercise Pattern Subjective data: Dati ko pa na ginagawang exercise yung paglalakad ko kase everyday yung trabaho ko sa pagmamasahe na home service. Hilig ko din pala magdrawing. Objective data: Patient is able to walk, stand, sit and lie on bed without assistance; weight is welldistributed; toes point straight ahead; full ROM, muscle strength of 5/5 in both upper and lower extremities; no retractions, no tenderness noted upon palpation; no adventitious sound heard upon auscultation; pulses also noted; Analysis: Readiness for enhanced self-care E. Sleep-Rest Pattern Subjective data: Di ako gaano makatulog, di kasi ako sanay dito pati dahil pa sa maraming bagaybagay. Objective data: Patient is sitting, awake, irritable; presence of dark circles under eyes noted; short attention span, slowed reaction upon interview. Analysis: Disturbed Sleep Pattern r/t altered environment as evidenced by the patients statement of alteration in normal sleep pattern F. Sensory-Cognitive Perceptual Subjective data: Di naman malabo panrinig ko pati di rin ako gumagamit ng pustiso. Objective data: Patient is awake; able to comprehend simple and complex commands; slowed reaction, short attention span upon interview; can distinguish different scents, pain and smooth stimuli; is oriented to time, person and place; has a good memory of recent and remote events; good grip reflex noted; Eyelid margins moist, pink, blinks bilaterally; Lashes short, evenly spaced; upper margins of lid cover approximately 3 mm; palpebral conjunctiva pinkish in color with no discharge noted; illuminated pupils constrict in 3 mm; EOMs intact in both eyes; Nostrils can identify scent correctly; can perform different facial expressions; hearing (+) Webers Test,Rinne Test=2AC:1BC; forehead, cheeks and chin sensitive to light touch, dull, sharp sensations Analysis: Readiness for enhanced decision-making

G. Role-Relationship Pattern Subjective data: Sobrang close kami ng family ko pati friends. Basta lagi sila andyan pati yung boyfriend ko. Laging nag-aalaga sa akin ngayon, yung tatay ko. At nakakatuwa na di naman din ako nakakalimutan ng mga kaibigan ko kasi bumibisita sila e. Yung iba pa nga kasama ko sa paghhome service ng massage therapy. Wala din ako nakakaalitan na kung sino man. Sinakripisyo ko yung pag-aaral para makapagtapos mga kapatid ko. Objective data: Patient communicates well with significant other; regular visits of father. Analysis: Readiness for enhanced family processes H. Self Perception- Self Concept Pattern Subjective data: Basta ang masasabi ko confident naman ako sa sarili ko at wala akong ikinakahiya. Objective data: Patient is, awake; slowed reaction, has no eye contact, short attention span upon interview; has good posture and steady gait. Analysis: Risk for powerlessness r/t to disturbed sleep pattern I. Coping-Stress Tolerance Pattern Subjective data: Di naman ako mabilis kabahan o mataranta. Di rin ako masyadong nag-alala sa sakit ko ngayon. Lahat yan dahil sa mga mahal ko sa buhay. Objective data: Patient is cooperative to procedures, calm, answers questions without hesitation. Analysis: Readiness for enhanced coping J. Value-Belief Pattern Subjective data: Lagi kami nagsisimba na mag-anak tuwing linggo. At matindi ang pananampalataya naming sa Diyos. Objective data: No religious article present Analysis: Readiness for Enhanced Spiritual Being

IX. LABORATORY & DIAGNOSTIC FINDINGS

Date: 8/6/2011 Test Sgpt Sgot Remarks: Date: 8/7/2011 TEST Prothrombin Time Control INR % activity Partial thromboplastin time Control

Time: 12:08:56 p.m. Result 54lu/L 114lu/L Time: 07:30:56 p.m. RESULT 11.4 12.0 0.95 108.1 46.9 30.0

Normal 6 37lu/L 10 -30lu/L

UNIT sec sec sec

REFERENCE 10 - 13

29 34

Date: 8/9/2011 Time: 03:31:44 a.m. TEST RESULT UNIT Hemoglobin Mass C 129 g/L MCH 28.7 pg Hematocrit 37 % MCV 84 fL MCHC 34 % RBC 4.5 x10^12/L WBC 5.9 x10^9/L Differential Count Neutrophils 20 % Stabs % Lymphocytes 50 % Monocytes % Eosinophils % Basophils 3 % Platelet 33 x10^9/L MPV 11.1 fL RBC Morphology NORMOCHROMIC, NORMOCYTIC Remarks: Atypical Lymphocytes = 17 INTERPRETATION OF LABORATORY AND DIAGNOSTIC TESTS:

REFERENCE 120 -140 27.5 33.2 37 47 80 94 32 37 4.0 4.5 5 -10 40 75 35 20 45 26 14 01 150 440 7.5-11.5

In the Laboratory and Diagnostic tests that was performed to the client, it showed that some results are not within the normal range. WBC are slightly below normal because the presence of infection invades the circulatory system and weakens the immune system which makes the patient susceptible to more diseases. Lymphocytes are greatly increased due to viral infection, neutrophils are depressed due to bacterial disease. Platelet count is extremely below normal. The client may be at risk for bleeding due to continuously failing or decreasing platelet count. Partial Thromboplastin time is greatly delayed by almost 13 seconds which show deficiency of fibrinogen. Vitamin K absorption are decreased because it synthesize prothrombin for blood clotting factors/blood clot. SGOT and SGPT are components in a liver function panel and they denote liver damage or necrosis. The patient has a slightly increased of SGOT and SGPT which may lead to hepatic impairement.

X. ANATOMY AND PHYSIOLOGY REVIEW Blood is a circulating tissue composed of fluid plasma and cells (red blood cells, white blood cells, platelets). Anatomically, blood is considered a connective tissue, due to its origin in the bones and its function. Bl o o d is the means and transport system of the body used in carrying elements (e.g. nutrition, waste, heat) from one location in the body to another, by way of blood vessels. Functions of Blood: 1 Transportation: o oxygen & carbon dioxide o nutrients o waste products (metabolic wastes, excessive water, & ions) 2 - Regulation - hormones & heat (to regulate body temperature) 3 - Protection - clotting mechanism protects against blood loss & leucocytes provide immunity against many disease-causing agents Components of Blood - average adult has about 5 liters (about 5 qts): 1 - Formed elements : o Red blood cells (or erythrocytes) o White blood cells (or leucocytes) o Platelets (or thrombocytes) 2 -P la s m a = water + dissolved solutes Red Blood Cells (or erythrocytes): 1 - Biconcave discs 2 - Lack a nucleus & cannot reproduce (average lifespan = about 120 days) 3 - Transport hemoglobin (each RBC has about 280 million hemoglobin molecules) 4 - Typical concentration is 4-6 million per cubic mm (or hematocrit [packed cell volume] of about 42% for females & 45% for males) 5 - Contain carbonic anhydrase (critical for transport of carbon dioxide) Three main classifications of blood cells derive from hematopoietic stem cells Myeloid cells. This includes macrophages (monocytes) and granular white blood cells (or granulocytes; neutrophils, basophils and eosinophils). Macrophages have a role in adaptive immunity, cooperating with T and B cells through antigen presentation and the production of cytokines. Erythroid-megakaryocytes. Erythrocytes (red blood cells) carry oxygen through blood vessels, whereas platelets derived from megakaryocytes work to prevent blood loss. Lymphoid cells. This includes T-cells and B-cells. Natural killer (NK) cells are thought to be the prototype of T cells. Thymic, as well as pre-thymic, T-cell progenitors are able to generate dendritic cells. B cells secrete antibodies Hemoglobin composed of globin (made up of 4 highly folded polypeptide chains) + 4 heme groups (with iron) each molecule can carry 4 molecules of oxygen called oxyhemoglobin when carrying oxygen & called reduced hemoglobin when not carrying oxygen can also combine with carbon dioxide & helps transport carbon dioxide from the tissues to the lungs

White blood cells (or leucocytes or leukocytes): have nuclei & do not contain hemoglobin typical concentration is 5,000 - 9,000 per cubic millimeter types of WBCs: o granular white blood cells include: neutrophils (50 - 70% of WBCs) eosinophils (1 - 4%) basophils (less than 1%) o agranular (or non-granular) white blood cells include: lymphocytes (25 - 40%) monocytes (2 - 8%) Granular white blood cells contain numerous granules in the cytoplasm, & their nuclei are lobed. Agranular white blood cells have few or no granules in the cytoplasm & have a large spherical nucleus. Granular white blood cells are produced in the bone marrow, while agranular white blood cells are produced in lymph tissue, e.g., Lymph nodes (specialized dilations of lymphatic tissue which are supported within by a meshwork of connective tissue called reticulin fibers and are populated by dense aggregates of lymphocytes and macrophages). The primary functions of the various white blood cells are: Neutrophils -p h a g o c y t o s i s (bacteria & cellular debris); very important in inflammation Eosinophils - help initiate and sustain inflammation and can activate T-cells (directly by serving as antigen-presenting cells and indirectly by secreting a variety of cytokines. Eosinophils can also kill bacteria by quickly releasing mitochondrial DNA and proteins (described below). Basophils - along with mast cells, play a role in inflammation and allergic responses. Release of histamine (that contributes to the 'symptoms' of allergies) by mast cells requires the production of antibodies (IgE) by B-cells and that process is regulated, in part, by cytokines produced by basophils. Monocytes - phagocytosis (typically as macrophages in tissues of the liver, spleen, lungs, & lymph nodes) & also important antigen-presenting cells Once distributed through the blood stream, monocytes enter other tissues of the body such as the liver (Kupffer cells), lungs (alveolar macrophages), skin (Langerhans cells), and central nervous system (microglia). Lymphocytes - immune response (including production of antibodies) Some important characteristics of White Blood Cells (particularly neutrophils): 1 - Phagocytic 2 - Capable ofd i a p e d e s i s (also called extravasation) 3 - Capable of ameboid movement 4 - Exhibitc h e m o t a x i s (attracted to certain chemicals, such as those released by damaged cells) Platelets( o r thrombocytes) 1 - Formed in the bone marrow from cells called megakaryocytes 2 - Have no nucleus, but can secrete a variety of substances & can also contract (because they contain actin & myosin) 3 - Normal concentration in the blood is about 250,000 per cubic millimeter 4 - Remain functional for about 7 - 10 days (after which they are removed from the blood by macrophages in the spleen & liver) 5 - Play an important role in hemostasis (preventing blood loss)

XI. PATHOPHYSIOLOGY

XII.

DRUG ANALYSIS MODE OF ACTION Gastric acid-pump inhibitor: Suppresses gastric acid secretion by specific inhibition of the hydrogenpotassium ATPase enzyme system at the secretory surface of the gastric parietal cells; blocks the final step of acid production INDICATIONS Short term treatment of active duodenal ulcer Treatment of heartburn and symptoms of GERD CONTRAINDICATION Contraindicated with hypersensitivity with omeprazole or its components Special precautions to those who have hepatic impairment SIDE EFFECTS CNS: Headache, dizziness Dermatologic: Rash, inflammation GI: Diarrhea, abdominal pain, nausea, vomiting NSG. RESPONSIBILITIES - Assess hypersensitivity to Omeprazole or any of its components - Assess for any skin lesions, reflexes, urinary output, abdominal exam, respiratory auscultation interventions - Administer before meals Provide health teaching: Avoid driving or doing hazardous tasks

GENERIC NAME Omeprazole

BRAND NAME Losec CLASSIFICATION Proton pump inhibitor

DOSAGE 40mg/capsule OD

GENERIC NAME Diclofenac BRAND NAME Flector DRUG CLASSES Analgesic (nonopioid) Anti-inflammatory Antipyretic NSAID DOSAGE 50mg/tab BID

MODE OF ACTION SIDE EFFECTS Inhibits prostaglandin synthetase to cause antipyretic and CNS: Headache, anti-inflammatory effects dizziness GI: nausea, GI INDICATIONS pain, diarrhea, Acute or long term treatment of mild to moderate pain, constipation rheumatoid arthritis, osteoarthritis, acute migraine CONTRAINDICATION Contraindicated with glaucoma, COPD, myocardial ischemia, impaired liver, metabolic or renal function, intestinal atony, stenosing peptic ulcer

NSG. RESPONSIBILITIES - Do not exceed the recommended dosage. - Give drug with food if GI upset.
-

Provide health teaching: Report rash, sore throat, fever, black, tarry stools, changes in vision, swelling in ankles or fingers.

GENERIC NAME Paracetamol

BRAND NAME Biogesic DRUG CLASSES Antipyretic Analgesic (nonopioid) DOSAGE 500mg/tab Q4 PRN

MODE OF ACTION Antipyretic: Reduces fever by acting directly on the hypothalamic heat-regulating center to cause vasodilation and sweating, which helps dissipate heat. INDICATIONS Relief of fever, minor aches and pain CONTRAINDICATION Hypersensitivity to acetaminophen

SIDE EFFECTS CNS: Headache CV: Chest pain, dyspnea GI: Jaundice GU: Acute renal failure Hypersensitivity: Skin rash

NSG. RESPONSIBILITIES Assess allergy to acetaminophen. Do not exceed the recommended dosage. Give drug with food if GI upset. Discontinue drug if hypersensitivity occur Provide health teaching: Do not take drug longer than 10 days Take the drug only for complaints indicated Report rash, unusual bleeding or bruising.

XIII. NURSING CARE PROCESS

Nursing Diagnosis Subjective cues: Risk for Parang may bleeding r/t allergy nga ako decreased nung kahapon pa platelet count e. Bigla na lang lumabas to sa buong katawan ko. Objective cues: -itching of the patient -noted presence of petechiae on both right and left and upper and lower extremities -noted presence of ecchymosis on right antecubital region (above elbow) -platelet count of 33x10^9/L

Assessment

Scientific Rationale A low platelet level can result from various factors such as decreased production of platelets within the bone marrow, increased destruction of platelets or increased consumption of platelets.

Planning After 8 hours of nursing intervention, the patient will be able to identify individual risk factors and engage in appropriate behaviors or lifestyle changes to prevent or reduce frequency of bleeding episodes

Interventions 1. Assess clients condition contributing to bleeding tendencies. 2. Discuss risk factors of bleeding 3. Assist patient in clients ADLs 4. Provide adequate hydration 5. Instruct patient for safety precautions 6. Remove all sharp objects around the bedside. 7. Allow the patient to eat vegetables and fruits 8. Teach the patient to schedule activities

Scientific Rationale 1. To know the clients status. 2. To provide awareness and knowledge to the patient 3. To prevent any falls or injuries. 4. To prevent blood stasis 5. To reduce the risk of acquiring bleeding 6. To avoid the risk for bleeding 7. To help the patient gain immunity 8. To provide restrictions

Evaluation After the nursing intervention, the client will identify the cause as well as the risk factors. Also, frequency of bleeding episodes will be prevented

Assessment Subjective cues: The patient verbalized, kulang ako sa tulog (dati 8 hrs tapos ngayon 5 hrs na lang. Di kasi ako sanay dito Objective cues: -observed a short attention span of patient -noted irritability by the patient

Nursing Diagnosis Disturbed Sleep Pattern r/t altered environment as evidenced by the patients statement of alteration in normal sleep pattern.

Scientific Rationale Altered environment simply means that the surroundings have changed. The change that took place does not help the client for it brings a deviation in their usual sleeping habit.

Planning At the end of 8 hours nursing intervention, the client will be able to verbalize good quality of sleep.

Interventions 1. Assess patients level of consciousness 2. Assist the patient in lying or sleeping 3. Schedule time of activities (v/s taking, health teaching) 4. Provide health teaching related to problem incurred 5. Provide an environment conducive to sleeping (turn off lights, provide drapings, raise side rails)

Scientific Rationale 1. To know the status of the patient 2. To guide the patient 3. To avoid interfering with sleep 4. To help the patient cope with the problem encountered. 5. To encourage or stimulate sleeping and provide adequate rest

Evaluation After the nursing intervention, the client will verbalize good quality of sleep.

Assessment Objective cues: -patients skin is smooth, warm touch, pale in color -Neutrophil count changed from 40-75 x 10^9/L to 20 x 10^9/L

Nursing Diagnosis Risk for infection r/t to inadequate secondary defenses specifically decreased neutrophil count

Scientific Rationale A low WBC count may be caused by decreased production of neutrophils or increased destruction of neutrophils

Planning After 8 hours of nursing intervention, the client will be able to verbalize understanding of risk factors contributing to infection and Identify prevention risk infection to of

Interventions 1. Assess clients condition that may contribute to infection. 2. Discuss to the client the risk factors to infection. 3. Provide adequate hydration 4. Maintain cleanliness by providing strict medical asepsis 5. Do not allow fresh flowers inside the room likewise, fresh unpeeled fruits 6. Check vital signs (most especially temperature) 7. Watch out for signs of inflammation on the IV status

Scientific Rationale 1. To know the status of the patient 2. To provide awareness and knowledge to the patient 3. To prevent blood stasis 4. To encourage an environment free from infection 5. To discourage the flow of microorganisms in the clients environment 6. To serve as a baseline data. Also this is an indicator of infection. 7. To avoid any entrance of microorganisms.

Evaluation After the nursing intervention, the client will verbalize understanding of risk factors adding up to infection as well as identify of how to prevent it